Poor Oral Health and Blood Pressure Control Among US Hypertensive Adults

Introduction and methods

Periodontitis, a chronic inflammatory disorder of tissues surrounding the teeth [1], is associated with many CV risk factors and related diseases, such as endothelial dysfunction [2-4], hypertension [5,6], atherosclerosis [7,8] and major CV events [5,6,9-12]. Although some studies have shown beneficial effects of periodontal treatment on blood pressure (BP) [13,14], data on the effect of periodontitis on BP control in patients with antihypertensive treatment are lacking. Therefore, this study aimed to examine the relation between periodontitis and uncontrolled hypertension in treated hypertensive patients enrolled in the National Health and Nutrition Examination Survey (NHANES).

This retrospective cross-sectional analysis of the NHANES assessed arterial BP in hypertensive adults with (n=1,834) versus without (n=1,694) periodontitis, aged ≥30 years on prescribed medicine for high BP with at least one natural tooth. Subjects with a history of heart transplant, artificial heart valve, congenital heart disease not including mitral valve prolapse, or bacterial endocarditis were excluded for periodontal examination.

Disease severity was defined as mild, moderate or severe according to the gold standard full-mouth periodontitis surveillance protocol following suggested Centers for Disease Control and Prevention/American Academy of Periodontology case definitions [1]. Arterial BP was measured by trained and calibrated physicians using a mercury sphygmomanometer according to standardized BP measurement protocols [15].

Treated hypertensive adults with periodontitis had 20% higher risk of unsuccessful antihypertensive treatment compared to those without periodontitis, which was no longer statistically significant after adjustment for CRP (OR: 1.19, 95%CI: 0.91–1.54, P=0.205).

Quartiles of periodontitis severity were identified at 1.07, 1.53, 2.01 and 6.03 mm for probing depth (PD) and 1.02, 1.56, 2.35 and 11.33 for clinical attachment loss (CAL). Treated hypertensive patients in the highest quartile of periodontal scores showed significantly higher ORs of uncontrolled BP, compared with those in the lowest quartile (both OR: 1.26, 95%CI: 1.04-1.52, P=0.018), which remained significant after multivariable adjustment, except when also adjusting for CRP.

Poorer SBP was achieved across all age ranges in treated patients with periodontitis vs without periodontitis (ΔSBP between groups according to model 2: 30–44 years of age: 2.05 mmHg, P<0.0001; 45–64 years of age: 2.30 mmHg, P<0.0001; ≥65 years of age: 2.50 mmHg, P<0.0001).

Periodontal disease severity analysis showed that participants with moderate disease had higher SBP (133.59±4.6) than those with mild disease (128.14±4.7, P<0.001) and those without periodontitis (131.08±5.0, P<0.001). Those with severe disease had significantly (Bonferroni-corrected for multiple comparisons) higher SBP (134.22±4.1) than all other disease severities.

Cubic spline analysis of the relation between PD (a measure of acute disease) or CAL (chronic disease) and SBP across different age ranges, suggested that PD affected SBP more in younger participants and CAL had more effect on SBP in older subjects.

Among untreated hypertensive patients (n=460) the mean SBP was 2.8-7.6 mmHg higher in those with periodontitis compared to those without periodontitis, depending on the adjustment model.

When the prevalences of having BP below vs. above the BP threshold of 130/80 mmHg were assessed, no difference according to periodontitis was observed in untreated patients (with periodontitis: below vs. above 130/80 mmHg: 15.9% vs. 33.8%, vs. no periodontitis: 17.4% vs. 32.9%, P=0.552), in contrast to what was observed in treated patients (with periodontitis: 20.9% vs. 31%, vs. no periodontitis: 21.5% vs. 26.6%, P=0.007), of whom more participants with periodontitis had a BP above the threshold.

Conclusion

Hypertensive patients without periodontitis show a better SBP during antihypertensive treatment by about 2.3-3.0 mmHg and lower odds of treatment failure than hypertensives without periodontitis. The data suggest that antihypertensive therapy in the presence of periodontitis may be less effective as compared with good oral health. Dedicated studies may focus on the effect of periodontal therapy on BP in treated hypertensive patients.

6. Holmlund A, Holm G, Lind L. Severity of periodontal disease and number of remaining teeth are related to the prevalence of myocardial infarction and hypertension in a study based on 4,254 subjects. J Periodontol. 2006;77:1173–1178. doi: 10.1902/jop.2006.050233